What are the Steps Involved in the Medical Credentialing Process?

Credentialing is essential for healthcare professionals in the US because it guarantees they have the necessary education, training, and experience to provide quality care. Healthcare providers are also required to be credentialed to meet the standards set by the regulatory bodies and professional organizations. Accrediting agencies, such as the Joint Commission, require all healthcare providers to undergo rigorous  credentialing processes such as  physician credentialing and medical credentialing. Credentialing is undertaken to verify the educational background, training,  licensure and competence of those providers. 

US healthcare providers can encounter several hassles during the credentialing process, including administrative burdens and delays in the credentialing process. There might even be certain issues in obtaining and verifying the necessary documentation, such as certifications, licensure, and transcripts. According to a survey by the American Medical Association, 34% of physicians reported running into hurdles while they obtained and verified documentation during the credentialing process.

The Credentialing Process at Capline Healthcare Management 

The medical credentialing process followed at Capline Healthcare Management is comprehensive, ensuring that all healthcare providers associated with the company meet the highest standard of quality and patient safety. 

Our medical credentialing process involves the collection of necessary documents from providers like licenses, board certifications, qualifications, and work experience, and then submit their application to the top insurance providers. We even conduct background checks and review the operating history of the practice. 

Capline Healthcare Management utilizes state-of-the-art technology to streamline the credentialing process and our medical credentialing specialist helps doctors with credentialing in a faster way, making the entire process more efficient.  

• Accelerate your application process by completing it twice as quickly as an in-house team.
• Stay up-to-date with the real-time status of your application or medical staff credentialing.
• Benefit from a dedicated expert who will handle your account.
• Eliminate the hassle of piles of paperwork and filling out forms.
• Ensure timely credentialing with healthcare plans.
• Receive real-time updates on your credentialing.

Steps in the Capline Healthcare Management Credentialing Process 

Medical credentialing is critical in ensuring the safety and quality of healthcare delivery in the United States. All qualifications held by the nurses, physicians, and other healthcare professionals are verified in this process. The process is required by law for any healthcare organization that is a member of the Medicare and Medicaid programs. Accrediting bodies like the Joint Commission also mandate it.  

Initial Documentation verification 

Verifying information available on the facility or practitioners begins by collecting information on the background, education, licenses, etc. The provider may deliver all of the data via email, software, or survey questionnaires. 

Generally, the health insurance plan company or healthcare facility collects this information. In certain cases, they might work with third-party Medical credentialing companies or agencies known as CVOs (Credential verification organizations) that take on the responsibility of collecting and verifying this data: 

• Work history (normally the CV or resume)
• Professional licenses 
• Certifications
• References
• Malpractice insurance certificates 
• Practice ownership details 
• Background checks 
• W-9

• Bank statements 
• Hospital Privileges     

Evaluation of applications

A contract request form is sent to the providers either online or through email to assess the eligibility of providers and if the network covers them. Once the Contract request form is submitted, the providers send in their paperwork for in-process the application. We then follow up till the application is fully completed.

The required documentation is completed at this stage, and exceptions are identified. Insurance facilities will likely do background checks by corresponding with medical schools, licensing agencies, or any other institutions that providers have mentioned in their data.  

If these licensing agencies and other bodies have made their information available online, the insurance facility might even use software tools to continuously monitor the data they have received. Certain healthcare organizations contain all their data in platforms that organize records and send updates. 

Irrespective of how the data is stored and accessed, the checks done in this phase include monitoring malpractice claims or any other medical incident that affects the validity of the provider credential:

• Access the provider’s NPI or National Provider Identifier
• Other points of access include the Federal Tax ID or Practice EIN (same as what’s mentioned in the W-9 form)  

Identifying top payers to which the claims need to go to first. 

In other words, we are prioritizing insurance providers. Identifying who the top payers are makes it easier while submitting multiple applications. Before contacting those payers, it is important to note that if a larger portion of the medical billing is through a particular provider, then start with that application.   

Also, remember the regulations surrounding individual insurers that maintained a predefined process for providers that hold insurance in other states. Stay familiar with individual insurers’ regulations. Some health insurance companies might allow for a more streamlined process for providers already insured in another state. That may mean quicker approvals for the credentialing in medical billing. Then, there are abbreviated applications for any credentialed in-state. 

CAQH registration 

The CAQH registration is the next step, and the CAQH ID is generated in this phase. Posting valid dates is critical for a smoother registration. For example, all dates are in the ‘month/years’ format – choose any other format, and the application will get rejected. CAQH also generates a notification every six months to reaffirm if all data registered is updated.  

Follow up 

The first four steps make up the first part of the credentialing review. In this phase, a reference number given by the insurance payer is documented in the records. This number proves useful when contacting insurance payers for missing or incorrect application details. Documenting follow-up calls and any other kinds of communication is a good practice.    

Fee scheduling 

The billing systems in place are updated regularly with information on payers – this is known as EDI (electronic data interchange) enrollment. Fee scheduling information is always given on the credentialing contract provided by payers. Always check this part before signing that contract. Sometimes, you may need to request fee schedules and even give your billing codes.

Capline Healthcare Management is a leading medical credentialing services provider in the United States. We have collectively helped more than 400 practices grow, with an impressive number. Connect now to know more.